Gilbert H.L. Tang

Peripheral Venoarterial Extracorporeal Membrane Oxygenation in Combination with Intra-Aortic Balloon Counterpulsation in Patients with Cardiovascular Compromise

Objectives: Patients with profound cardiovascular compromise have poor prognosis despite inotropic and intra-aortic balloon pump (IABP) support. Peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) offers these patients temporary support as a bridge to various options including the ‘bridge to recovery. Methods: We studied the outcomes of 135 patients who underwent peripheral V-A ECMO and concomitant IABP implantation in our hospital from 2007 to 2012 for various clinical indications. The ECMO circuit consisted of a centrifugal pump and an oxygenator. Results: V-A ECMO was implanted in the cardiac catheterization laboratory in 51 patients (37.8%), at the bedside in 5 (3.7%) and in the operating room in 79 (58.5%). Mean duration of support was 8.5 ± 7.1 days. Median length of stay was 28 days (interquartile range 14-62). Complications included bleeding at the access site in 14.1%, stroke in 11.1% and vascular complications requiring intervention in 16.3%. Overall inhospital survival was 57.8% with outcomes including heart transplantation (3%), implantable left ventricular assist device (8.1% as bridge to transplantation and 6.7% as destination therapy), surgery (7.4%) and myocardial recovery (40.7%). Prior IABP use and axillary cannulation were independent predictors of reduced inhospital mortality, stroke or vascular injury. Conclusions: Peripheral V-A ECMO with IABP is an effective therapy for patients with severely compromised cardiovascular function. It offers reasonable survival and a spectrum of definitive options from ‘bridge to recovery to heart transplantation for the management of this critically ill population.

Transcatheter aortic valve replacement: current developments, ongoing issues, future outlook.

Since the first clinical implantation in 2002, transcatheter aortic valve implantation or transcatheter aortic valve replacement (TAVR) has become an established therapy in the treatment of symptomatic severe aortic stenosis in patients deemed too high risk for surgical aortic valve replacement. With over 50,000 implants performed in more than 40 countries, a large amount of clinical data have emerged in this rapidly growing field. Careful patient selection, systematic risk stratification, optimal valve sizing, meticulous procedural techniques, and complications management are all important elements to achieve good outcomes. However, several critical issues exist with TAVR that need to be addressed before it can become more widely adopted. Quality of life improvement and cost-effectiveness of TAVR, when compared to surgical aortic valve replacement, remain uncertain in lower risk patients. Stroke, paravalvular leak, vascular complication, bleeding, and heart block represent only a few of the key concerns in this therapy. Valve-in-valve procedures are becoming a novel application of transcatheter heart valve in the treatment of a degenerated bioprosthesis, and next generation heart valves that address some of these ongoing issues are currently under evaluation. Future prospective studies will allow us to refine this therapy and optimize outcomes in this high-risk patient population.

Failed repeated thrombolysis requiring left ventricular assist device pump exchange

A 51‐year‐old male with untreated hepatitis C infection, cirrhosis, and dilated cardiomyopathy with a HeartMate II LVAD presented with right heart failure and cardiogenic shock, INR of 7, hemolysis, and renal failure. Acute LVAD thrombosis was suspected. Alteplase was injected into the inflow cannula of the LVAD with little effect. Intravenous alteplase was given but failed to restore an adequate pump output, resulting in the need for emergency pump exchange. The patient had an uncomplicated postoperative recovery and was discharged uneventfully. Inspection of the pump identified a thrombus wedged between the spines of the impeller. Our case highlights the challenges in managing pump thrombosis which is often resistant to thrombolysis and may instead rely upon prompt surgical intervention to be resolved.

The International Multicenter TriValve Registry Which Patients Are Undergoing Transcatheter Tricuspid Repair

OBJECTIVESnThis study sought to develop a large, international registry to evaluate the diffusion of these approaches and investigate patient characteristics and initial clinical results.nnnBACKGROUNDnSeveral transcatheter tricuspid valve therapies are emerging as therapeutic options for patients with severe symptomatic tricuspid regurgitation (TR), generally a high-risk surgical population.nnnMETHODSnThe TriValve (Transcatheter Tricuspid Valve Therapies) registry included 106 high-risk patients (76 ± 9 years of age; 60.4% women; European System for Cardiac Operative Risk Evaluation II 7.6 ± 5.7%) from 11 cardiac centers, with severe TR.nnnRESULTSnA total of 35% of the patients had prior left heart valve intervention (surgical in 29 of 106 and transcatheter in 8 of 106 patients). Right ventricular (RV) dysfunction (tricuspid annular plane systolic excursionxa0<17 mm) was presentxa0in 56.3% of the patients; 95% of the patients were in New York Heart Association functional class III to IV. Thexa0etiology of TR was functional in 95.2%, and the mean tricuspid annulus was 45.4 ± 11 mm. In 76.9% of the patients,xa0the main location of the regurgitant jet was central; pre-procedural systolic pulmonary artery pressure was 39.7xa0± 13.8 mmxa0Hg; and the inferior vena cava was severely dilated in most of the patients (27.4 ± 6.8 mm). Implanted devices included MitraClip (nxa0= 58), Trialign (nxa0= 17), TriCinch (nxa0= 15), FORMA (nxa0= 7), Cardioband (nxa0= 5), and caval valve implantation (nxa0= 3). One case had combined Trialignxa0+ MitraClip. Patients treated with the different techniques were similar in terms of European System for Cardiac Operative Risk Evaluation II and degree of RV dysfunction. In 68% of the cases the tricuspid intervention was performed as an isolated procedure. Procedural success was achieved in 62%xa0of cases. At 30-day follow-up, all-cause mortality was 3.7%, with an overall incidence of major adverse cardiac and cerebrovascular events of 26%; 58% of the patients were New York Heart Association functional class I or II at 30 days.nnnCONCLUSIONSnPatients currently undergoing transcatheter tricuspid valve therapy are mostly high risk, with a functional etiology and very severe central regurgitation, and do not have severely impaired RV function. Initial results suggest that transcatheter tricuspid valve therapy is feasible with different techniques, but clinical efficacy requires further investigation.

Association Between Hospital Volume and 30-Day Readmissions Following Transcatheter Aortic Valve Replacement

Importance With the approval of transcatheter aortic valve replacement (TAVR) for patients with severe symptomatic aortic stenosis at intermediate surgical risk, TAVR volume is projected to increase exponentially in the United States. The 30-day readmission rate for TAVR was recently reported at 17.9%. The association between institutional TAVR volume and the 30-day readmission metric has not been examined. Objective To assess the association between hospital TAVR volume and 30-day readmission. Design, Setting, and Participants In this observational study, we used the 2014 Nationwide Readmissions Database to identify hospitals with established TAVR programs (performing at least 5 TAVRs in the first quarter of 2014). Based on annual TAVR volume, hospitals were classified as low (<50), medium (≥50 to <100), and high (≥100) volume. Rates, causes, and costs of 30-day readmissions were compared between low-, medium-, and high-volume hospitals. Data were analyzed from November to December 2016. Exposure Transcatheter aortic valve replacement. Main Outcomes and Measures Thirty-day readmissions. Results Of 129 hospitals included in this study, 20 (15.5%) were categorized as low volume, 47 (36.4%) as medium volume, and 62 (48.1%) as high volume. Of 16 252 index TAVR procedures, 663 (4.1%), 3067 (18.9%), and 12 522 (77.0%) were performed at low-, medium-, and high-volume hospitals, respectively. Thirty-day readmission rates were significantly lower in high-volume compared with medium-volume (adjusted odds ratio, 0.76; 95% CI, 0.68-0.85; Pu2009<u2009.001) and low-volume (adjusted odds ratio, 0.75; 95% CI, 0.60-0.92; Pu2009=u2009.007) hospitals. Noncardiac readmissions were more common in low-volume hospitals (65.6% vs 60.6% in high-volume hospitals), whereas cardiac readmissions were more common in high-volume hospitals (39.4% vs 34.4% in low-volume hospitals). There were no significant differences in length of stay and costs per readmission among the 3 groups (mean [SD], 5.5 [5.0] days vs 5.9 [7.5] days vs 6.0 [5.8] days; Pu2009=u2009.74, and

Transcatheter mitral valve replacement: design implications, potential pitfalls and outcomes assessment.

13 886 [18 333] vs

Selective cerebral perfusion for cerebral protection: what we do know.

14 135 [17 939] vs

Unroofed Coronary Sinus in an Adult

13 432 [15 725]; P = .63, respectively). Conclusions and Relevance We report for the first time, to our knowledge, an inverse association between hospital TAVR volume and 30-day readmissions. Lower readmission at higher-volume hospitals was associated with significantly lower cost to the health care system.

Bench Mitral Valve Repair of Donor Hearts Before Orthotopic Heart Transplantation

Transcatheter mitral valve replacement (TMVR) is an emerging new treatment option in patients with advanced mitral valve disease deemed a high or prohibitive risk for surgery. Designing an ideal TMVR device requires a detailed understanding of different mitral valve pathologies and the complex, dynamic anatomy and physiology of the mitral apparatus. This review aims to critically evaluate design implications in TMVR in the context of mitral valve disease, imaging prerequisites, procedural approaches, potential complications, and outcomes assessment.

Excellent outcomes with use of synthetic vascular grafts for treatment of mycotic aortic pseudoaneurysms after heart transplantation.

Selective antegrade cerebral perfusion (SACP) for aortic arch surgery has evolved considerably since it was first reported. Various pressure rates have been investigated through animal models, as has the effect of warmer perfusate temperatures and hematocrit. Clinical research into pH management, the role of unilateral and bilateral perfusion, and core temperatures have further refined the procedure. We recommend the following protocol for SACP: perfusion pressure between 40-60 mmHg, flow rates between 6-10 mL/kg/min, and perfusate temperature of 20-28 °C; core cooling to 18-30 °C contingent on duration of arrest; alpha-stat pH management; hematocrit between 25-30%; near infrared spectroscopy to monitor cerebral perfusion; and bilateral perfusion when prolonged durations of SACP is anticipated.